Chandler et al.

Human Resources for Health 2013, 11:13

http://www.human-resources-health.com/content/11/1/13

RESEARCH Open Access

Aspirations for quality health care in Uganda:

How do we get there?
Clare I R Chandler1*, James Kizito2, Lilian Taaka2, Christine Nabirye2, Miriam Kayendeke2, Deborah DiLiberto3
and Sarah G Staedke3

Abstract
Background: Despite significant investments and reforms, health care remains poor for many in Africa. To design an
intervention to improve access and quality of health care at health facilities in eastern Uganda, we aimed to understand
local priorities for qualities in health care, and factors that enable or prevent these qualities from being enacted.
Methods: In 2009 to 2010, we carried out 69 in-depth interviews and 6 focus group discussions with 65 health workers
at 17 health facilities, and 10 focus group discussions with 113 community members in Tororo District, Uganda.
Results: Health-care workers and seekers valued technical, interpersonal and resource qualities in their aspirations for
health care. However, such qualities were frequently not enacted, and our analysis suggests that meeting aspirations
required social and financial resources to negotiate various power structures.
Conclusions: We argue that achieving aspirations for qualities valued in health care will require a genuine reorientation
of focus by health workers and their managers toward patients, through renewed respect and support for these
providers as professionals.
Keywords: Africa, Access to health care, Power/empowerment, Quality of care, Relationships, Health care

Background structural issue: a function of interactions between clients,

In spite of significant global investment, the majority of de-
veloping countries are not on target to achieve Millennium
Development Goals 4 and 5, to reduce the under-5 morta-
lity rate by two-thirds and the maternal mortality ratio by
three-quarters between 1990 and 2015 [1]. Failure to reach
these targets has been blamed on health system bottle-
necks that prevent the ability to scale up coverage of key
interventions [1,2]. Inadequate building blocks of health
systems, namely the numbers and distribution of health
workers, equipment, supplies and infrastructure, are cited
as contributing to low coverage of health interventions,
with median rates of correct treatment of childhood diar-
rhoea, pneumonia and malaria below 50% [3]. Accelerated
efforts to meet the 2015 targets focus on evidence based
interventions to be supported by strengthened health
systems (ibid.). However, many argue that the way services
and programs are enacted in practice is a social as well as a
* Correspondence: clare.chandler@lshtm.ac.uk
1
Department of Global Health & Development, London School of Hygiene &
Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
Full list of author information is available at the end of the article
communities, health workers and systems [4,5].
Meeting a populations expectations from provider
services has been recognised as central to health system
performance [6]. The importance of meeting health worker
needs in order to deliver good quality, patient-oriented
services has also been recognized [7,8]. However, many
interventions continue to take a magic bullet format, with
limited effects. Interventions such as user fees for patients
have not been shown to improve access or health out-
comes, or to decrease health expenditure [9], and skills
training and guideline changes aimed at health workers
have had limited impacts on changing practices [10,11].
Likewise, investment in human or equipment resources in
efforts to strengthen health systems have had limited
effect in the absence of efforts to improve health-service
management and coordination [2].
Uganda has seen the implementation of many programs
intended to improve health and access to health care since
the early 1990s. However, health, and access to health care
remain poor across the country [12]. Social studies of the
introduction of these interventions suggest that their

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Chandler et al. Human Resources for Health 2013, 11:13
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limited effects may be attributable to a lack of alignment
between programme priorities, defined externally to the
local population, and local priorities [13-17]. The design of
health programs does not appear to take these local realities
into account. Understanding local aspirations and the
moral landscapes into which programs are introduced and
enacted may provide insights for more nuanced approaches
to improving health care [18]. Intervention design built
upon the lived realities of those enacting health care differs
from regular programmatic approaches, but may provide
alternative ways to improve health through better services
in rural Uganda and in other areas of Africa.
We undertook a qualitative study, alongside a large
census and health-provider survey in 2009 to 2010, to
understand 1) priorities for quality in health care from
the perspectives of health workers and community
members in Tororo District, Uganda and 2) factors
potentially amenable to change that could enable these
qualities to be enacted, thereby increasing equitable
access to good quality health care for the local popula-
tion. Our focus was particularly on health care for chil-
dren, as a key vulnerable group. This qualitative research
informed the design of a complex health-facility inter-
vention that is under evaluation as a large cluster
randomised trial in Tororo District from 2011 to 2013
(clinicaltrials.gov NCT01024426).
Theoretical orientation
Anthropological studies have repeatedly emphasized the
importance of social relationships in the enactment of
health care [19-21], and have drawn attention to how
these social and cultural realities are embedded in particu-
lar political-economic and historical contexts [22]. In this
article we analyse the lived realities of the enactment of
health care, as expressed by community and health-worker
participants, in the context of the local political history of
the study area. We use the term enactment to describe the
moments when health care is produced, rather than the
terms access or service provision, which evoke concepts more poor people sought care at public facilities. However,
such as utilization and availability, based on numbers and the proportion of poor households facing catastrophic
structures. Studies of access to health care in practice
suggest its enactment is a dynamic interaction between
populations and services, and health seekers and health
workers, over extended time periods, often in contexts of
social and economic as well as health vulnerability
[5,16,23-26]. In this article, we attempt to draw together
meanings and practices of care as interpreted and experi-
enced by actors who seek and provide health services.
Study setting
Uganda: health system changes
During the economic deterioration of the 1970s and
1980s, when the weakened Ugandan state struggled to
provide free health services and to pay for health-worker
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salaries and the upkeep of facilities [27], health workers
were observed to develop survival strategies to cope
with scarce resources, including adopting external
profit-making practices [28], and the use of public
resources in their private practices [29].
To improve accountability at the local level, health
care in Uganda was decentralized in 1993. Local authorities
were handed responsibility for health-care activities outside
of hospitals. This included responsibility and authority to
set fees for services provided, which could feed into district
or facility funds. Contrary to hopes that introducing fees
would formalize payments, the ability to charge for services,
together with continued low salaries, resulted in increased
leakage of drugs [29], mismanagement of funds [30], infor-
mal requests for payment from patients, and reduced qua-
lity and accessibility of care [31]. Health workers were
continuing to rely on their survival strategies implemented
in earlier years [15]. The shift in power to charge fees was
mirrored by a shift in power to recruit staff and allocate
resources at the local level, which was intended to empower
responsiveness to local needs. In practice, however, the abil-
ity of local politicians to define local needs created friction
within districts. Health workers needed to reinforce their
relationships with leaders who interpreted decentralized
policies as preferences for locally born staff [32]. Selection
criteria for training opportunities were not based on train-
ing needs, with in-charges attending more seminars and
reaping the benefits [15]. With competition for income
opportunities, health workers reportedly prioritized atten-
dance at meetings for which allowances would be paid over
providing care to patients (ibid.).
In 2001, Ugandas President, Yoweri Museveni, abolished
user fees as part of his election campaign. The health sector
strategic plan for the turn of the millennium identified the
health sector as playing a key role in poverty eradication
and socioeconomic development in the country [33].
Analyses of the removal of user fees in Uganda suggest a
positive impact; quality of care did not decrease [34], and
health expenditures did not decrease [35]. For health
workers, removal of user fees meant a sudden influx
of patients to health centres, stretching supplies, staff
and space [36].
Tororo: interventions and health
The significant changes in the organization and delivery
of health care in Tororo District over the past 20 years
reflect both the changes on-going in Uganda nationally
and various donor activities in the district. Tororo was
one of the first districts in Uganda to be decentralized,
in 1994, with implications similar to those described
elsewhere in the country [17]. Subsequent upgrading of
health facilities to the vision of the Health Sector
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Strategic Plan [33], including a referral level health
centre (Health Centre-HC-IV) per county, a mid-level
HCIII per sub-county and a low-level HCII per parish,
was slow to be implemented. In 2003, Tororo District
had only 50% of the desired facilities [37], with a staffing
gap of 73% [17]. In 2009, our survey in one sub-district
of Tororo found that while higher level facilities were in
place, only 56% of the parishes had health facilities and
there was a 41% staffing gap of those officially in post
[38] when compared with staffing norms set out in the
2005 Health Sector Strategic Plan [39]. Donors have
contributed significantly to district funds, through both
a sector-wide approach and direct support to a multi-
tude of programs, particularly to HIV/AIDS care and
prevention and malaria prevention and control [40].
In spite of these efforts, data relating to health and
wealth of citizens of Tororo in 1996 and 2003 suggest no
significant improvement in socioeconomic status of house-
holds overall, and some worsening of childhood illnesses
including diarrhoea, fever and acute respiratory infections
[40,41]. Our census survey in 2009 to 2010 showed the
area continued to be poor, with few households having
electricity (1%) and most obtaining water from a public
borehole or well/spring. A quarter of households had no
toilet facilities. Of the heads of households, 24% had
received no formal education. Mortality in children under
5 years of age was estimated at 11% [38]. A survey among
patients and community members in 2003, at a time when
drug availability was reported to be strong, suggested qua-
lity of services was perceived to be generally good although
dissatisfaction was expressed with waiting times, staff avai-
lability, some rude staff, language difficulties and having to
pay for treatment [17]. In both 2003 and 2005, health-care
workers complained of staff shortages; limitations in trai-
ning opportunities, working equipment, drug supplies, and
working space; and difficult relationships with politicians
[17,36]. Both surveys recommended the increase and use
of funds to fill gaps in staffing, equipment, supplies and
technical skills.
West Budama North: health facilities
We carried out this qualitative study in the West
Budama North sub-district of Tororo, where the popula-
tion is largely of the Japadhola ethnic group. Seventeen
government-run health centres were operational in the
study area, including 12 health centre (HC) IIs, the lowest
level where medicines are dispensed, four HCIIIs, where
patients may stay overnight and babies are delivered, and
one HCIV, which provides referral care and has several
wards. HCIIs and HCIIIs reported seeing between 50 and
60 patients per day, and the HCIV around 200. HCIIs
were staffed by one to three health workers, while HCIIIs
had approximately ten, and the HCIV had 36 health
workers, although only around half of the health workers
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stationed at these higher level facilities were available to
work on a given day. Shortages in drugs and equipment
were noted at all HCs and many lacked running water and
electricity. Of the health workers at facilities visited in the
survey, 26% were volunteers with no official post, and
frequently no qualifications, but whose roles included
dispensing medicines, giving immunizations and even
delivering babies. The study area also housed a number of
private drug shops, also known as clinics, usually owned
by health workers.
Methods
After an intensive training course in the studys objec-
tives and in methods, led by CC and based on a manual
for Quality Information in Field Research [42], a team
of six social scientists carried out fieldwork in Tororo
District from September 2009 to March 2010. Activities
specific to the research question presented here consisted
of a series of in-depth interviews followed by focus group
discussions (FGDs) with health workers and a series of
FGDs with community members. The social scientists were
based in a rural town for the duration of fieldwork, enab-
ling a richer understanding of the local political, economic
and health context. Three of the team were from the local
area and able to speak Japadhola while the remaining team
members were from other areas of Uganda and carried out
fieldwork in Luganda or English.
Study sample
Community focus group discussions were held with
primary care givers of children under 5 years of age, as
the most frequent users of primary care services, and
with heads of households, deemed important for their
influential role in accessing health care. We used a sam-
pling matrix (Table 1) to allocate different subgroups of
interest among ten FGDs, stratified by each of the five
sub-counties in the study area, communities that had a
health facility within and outside of their parish, age
group of primary caregivers, and gender of household
heads. Further FGDs would have been conducted if new
themes continued to emerge in any sub-group.
All health workers at health facilities in the study area
were invited to participate in an in-depth interview,
including volunteers. All health workers were also eli-
gible for participation in subsequent FGDs. To facilitate
open discussion, FGDs were held separately for the three
levels of health facility, and within these, separate FGDs
were held for those with higher health qualifications,
such as nursing officers and clinical officers, and for
those with lower or no health qualifications, such as
nurse assistants or volunteers. For the lowest level health
centres, we invited those in-charge of their health
centres to a separate FGD.
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Table 1 Sampling matrix for community focus group discussions
Primary Caregivers
<30 years >30 years
SC1 SC2 SC3 SC4
PHC PHNC PHC PHNC
FGD201 FGD202 FGD203 FGD204
SC, sub-county, with numbers randomly allocated to sub-counties in West Budama North;
PHC, parishes with health centres; PNHC, parishes with no health centres;
FGD, Focus Group Discussion study identification number.
Participant invitation
Community leaders were informed about the study and
were asked for permission to carry out the fieldwork.
They were then asked to work with the study team to
identify 8 to 12 participants to represent the subgroups
of primary care givers and household heads from their
communities. Participants were invited to attend the dis-
cussion at a local community hall or school classroom
and refreshments and a transport refund were provided.
Those in charge of health facilities were asked for
permission to carry out the study and to provide a list of
health workers posted to the facility. Health workers were
invited to participate in an in-depth interview at their
convenience and were contacted again to participate in a
focus group.
Focus group discussions and in-depth interviews
Participants were provided with an information sheet,
which was read and discussed with a member of the study
team. Participants who agreed to take part and to be audio
recorded were asked to provide witnessed verbal consent.
For the FGDs, each participant was given an identification
badge with a number for anonymity and rules for confiden-
tiality were discussed with each group. The FGDs and inter-
views then followed a topic guide, facilitated by a member
of the study team in English, Japadhola or Luganda. The
community participants were asked to discuss their experi-
ences with illnesses and treatment seeking for their
children, their perceptions of different providers and for
suggestions on how to improve the delivery of care and
appeal of public health facilities. Health workers were asked
to discuss definitions of quality of care, opinions about their
own delivery of care, relationships with patients and
colleagues, and suggestions for improving quality of care
and appealing to the community. Extensive notes and a
contact summary were completed for each FGD and inter-
view, shared and discussed in real time with the broader
study team. Audio recordings were transcribed and
translated and field notes were integrated. Each transcrip-
tion and translation was cross-checked for accuracy and
then imported, together with participant demographic in-
formation, into NVivo version 8 (QSR International,
www.qsrinternational.com) for coding and analysis.
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Heads of Household
Female Male
SC5 SC1 SC2 SC3 SC4 SC5
PHC PHNC PHC PHNC PHC PHNC
FGD205 FGD206 FGD207 FGD208 FGD209 FGD210
Analysis
Analysis was on-going during and after fieldwork. This
enabled us to incorporate issues arising, such as pay-
ment for services, into subsequent interviews and FGDs.
Coding involved labelling ideas in transcripts and orga-
nizing these under headings that represented meanings
underlying groups of ideas. After coding the first few tran-
scripts from each participant group, the team agreed on a
working template in which to code subsequent tran-
scripts. Two members of the team undertook coding of
the community transcripts and three the health worker
transcripts. Each coded into separate NVivo files, which
were merged frequently and the coding templates
updated by CC, to reflect new ideas and themes emer-
ging. Higher level analysis, linking themes together into
broader concepts, evolved through a series of whole
team discussions about the data and consultation of
literature and theory.
Ethics
The study was approved by the Ugandan National Council
for Science and Technology (HS 644), the Makerere
University Faculty of Medicine Research and Ethical
Committee (2009149) and the London School of Hygiene
and Tropical Medicine Ethics Committee (5591).
Results
We found that health-care workers and seekers valued
technical, interpersonal and resource qualities in their aspi-
rations for health care. However, such qualities were fre-
quently not enacted, and our analysis suggests that meeting
aspirations required social and financial resources to nego-
tiate various power structures. In order to build on existing
literature, which is extensive in describing priorities in
health care qualities, we provide only a short summary of
the qualities valued by participants and then focus on the
latter issues of the enactment of care.
Participants
In all, 69 health workers were interviewed, and 65 took
part in 6 FGDs (Table 2). The mean age of health
workers was 37.5 years, with a median of 5 years experi-
ence as a health worker. Over half were female and most
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Table 2 Demographic details of health worker Valued qualities in health care

participants at each health centre level
Total (N = 69)
Age (years; mean, sd)
Gender (number of females, percent)
From the area (number, percent)
Years worked as a health worker (years; median, IQR)
Position at health centre (number, percent)
In-charge
Nurse/midwife
Other trained health worker
Nursing assistant
Volunteer
Highest level of education (number, percent)
Primary
Secondary
Certificate
Diploma/Bachelors
IQR, interquartile range.
who worked at lower level health centres were originally
from the area. By contrast, most health workers from
higher level health centres originated from outside of
the area. A majority of health workers had at least a
certificate level of education, with the most qualified
working at the highest level health centre. However,
17.5% of those working at health centres had no health
qualification, a majority of whom were volunteers.
A total of 113 community members took part in 10
FGDs (Table 3). Primary caregivers were younger than
heads of household with a mean age of 33.8 and. 45.9
years, respectively. All primary caregivers were female,
while 41% of the household heads were female, purpo-
sively selected for two of the FGDs. Participants in the
two subgroups had similar numbers of children - a mean
of 4.4. Participants were generally not well-educated;
30% (mostly women) lacked any formal education, and
only 22% had attended any secondary school, all of whom
were male.
Both community and health-care worker respondents
conceptualized access to quality health care as a com-
37.5 (10.8) prehensive therapeutic process: a compound of tech-
41 (59) nical, interpersonal and resource factors. Respondents
identified room for improvement on all fronts. Tables 4
43 (62)
and 5 summarize the qualities valued by health workers
5 (0.1 to 37)
and patients in our study sample.
15 (22) Technical quality of care
15 (22) An important quality in health care described by both
9 (13) health workers and community respondents was good
clinical care and treatment, entailing examination, inves-
11 (16)
tigation and diagnosis, followed by giving the right treat-
19 (27)
ment to patients. We noted that such technical qualities
were most often listed among other services valued in
1 (1.5) health care, as exemplified by this health worker,
11 (16)
45 (65) Good quality health care. Its receiving patients in a
humble manner and giving them the correct
12 (17.5)
treatment at the right time and a right diagnosis. Even
counseling them and advising them. (Nursing aide at
HC06, interview #41).
Interpersonal quality of care
Both health workers and community members valued
interpersonal qualities highly in the delivery of good
health care. These extended beyond providing advice or
education to patients to the attitudes conveyed through
receiving and welcoming patients, giving explanations
and expressing concern and reassurance.
You first welcome, that one will make that person free
and will make her air out her problems that she may
be in need of telling you. There is also introducing
myself to the patient, greeting the patient, then later
on you can ask the patients what her problems are
and attend to with keen interest, not just when the
mind is very far . . . the focus should be on the client,
and the mother or the client may know that you have
been attending to her or her problems. (Midwife at
HC15, interview #81)

Table 3 Demographic characteristics of community participants

Primary caregivers (n = 55) Heads of households (n = 58) Total (N = 113)
Number of participants in a group (range) 11 (10 to 12) 12 (11 to 12) 11 (10 to 12)
Mean age (range) 33.8 (18 to 55) 45.9 (20 to 80) 40 (18 to 80)
Number female (%) 55 (100%) 24 (41%) 79 (70%)
Mean number of children (range) 4.8 (1 to 11) 4.1 (0 to 10) 4.4 (0 to 11)
Number with no formal education (%) 14 (25%) 20 (34%) 34 (30%)
Number with any primary education (%) 35 (64%) 19 (33%) 54 (48%)
Number with any secondary education (%) 6 (11%) 19 (33%) 25 (22%)
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Table 4 Qualities valued in health care by health worker In spite of united aspirations for good quality care to
respondents incorporate good interpersonal skills and humility, the
Quality Number of health workers saying experiences of many community participants suggests
they valued this quality in that these aspirations were often not achieved in prac-
health care (of 69 interviews)
tice, discouraging patients from attending health centres.
Clinical care and treatment 34
Community respondents felt that reform in health
Availability of drugs, staff, 22 worker attitudes was urgently needed.
equipment and infrastructure
Good interpersonal interactions 21 There are some health workers who have bad
with patients
manners, they even want to beat you with your
Giving advice 20
child, when a child is very sick, you have gone to
Welcome and guidance for the 12 call them but again they want to beat you, chase or
patient
send you away, sometimes [you] may even fall. So
Being professional 11 we were requesting that such habits should stop,
we should be handled with good manners. (Female
household head, respondent 8 in FGD #204)
The musawo [health worker] working there should
welcome you, ask you questions very well. And you Resources and quality of care
also explain to them. You know there are eyes [looks] An essential quality in good health care was availability
that also scare. Then your heart beats. Then you fail of resources, particularly of drugs and other equipment
to say what you wanted to say. You know there is a such as syringes and gloves, as well as availability of
way we keep ourselves: you know someone who is human resources to provide swift treatment. Lack of these
educated and the one that is not. There is a way he/ resources, or charges made for access to resources, was
she can take you. So you will just sit there like a also considered to undermine technical and interpersonal
stupid person. The child is breathing badly from your aspects of care.
hands but you are just there like a stupid person, very
useless, surely when you know nothing. Even those I think good quality health care is when we have all
things written on the door you do not even know the required logistics in place . . . in terms of
where to enter. But if it were a kind musawo, who medicines in the health facilities and the lab should
God created with kindness and was raised up well, have whatever is needed there, and things like
reaches and sees that who is this who has reached, injections should all be in place, the medical staff
welcomes you well, ask you something carefully. must be there ready to serve the community. But you
Should teach you well, slowly, ask you while talking realize that Tororo District is operating with about
slowly. That is when you will remember everything. 47% of the staff required here. So that means that we
(Primary care giver, respondent 9 in FGD #209) are understaffed, and yet the influx of the community
is great, who come for treatment and even the drug
Table 5 Qualities valued in health care by community supply is seasonal. They have brought today but after
respondents one week there will be no drugs. (Health inspector at
Quality Number of community focus HC01, interview #08)
groups saying they valued this
quality in health care (of 10
focus group discussions) I also have a problem with that health centre. That
Free and timely services at the health 10 place is the only health centre that actually represents
centre the whole sub-county. But that place operates; I dont
Good interpersonal interactions with 10 know whether I should say that it operates for half a
health workers day, or for a quarter day. Because when they [are
Good management of health centre and 8 supposed to] start at 8 am, by 1 pm, there is nobody
resources
there, like a health worker. (Male household head,
Good treatment provided by health 8 respondent 7 in FGD #206)
workers
Good consultations, including asking 8 A district distributed primary health care fund (PHC) is
questions, examining and testing patients
intended to pay for everyday supplies such as cleaning
Welcome and orientation of patients 7
materials, or for transport to fetch drugs, or to make
Advice and explanations given to 7 photocopies for reports to the district, or to pay for people
patients
to clear bushes or to clean toilets at health centres.
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However, the PHC fund had not been received by health
centres in the study for at least 6 months, with ramifica-
tions for health centre infrastructure and staff morale,
Now like nowadays we dont have PHC, the
compounds are very bushy, which means you have
to pull your own money to give the porter [casual
labourer] . . . the recording book is finished is there,
you have nowhere to write, you have to pull money
and buy. Sometimes the nurse is rude [group laughs]
but there are so many reasons why the nurse is rude.
(In-charge of an HCII, respondent 2 in FGD #104)
All community FGDs included unprompted discus-
sions about requests for payment for services that are
officially free, reporting serious results for the poorest
who were unable to pay, and discouragement of many
from seeking care at health centres.
For me when I reach there [at the health centre], it is
the money issue that scares me, because they will
need money from me when I dont have, yet my child
is badly off, may be requires putting on drip, but there
is no money. So instead they will chase me with a sick
child that I go and look for money, now for me, I am
a poor person, I just have to first dig somebodys
garden, before getting money and this then means
that the child will have died, so that money issue is
what I dont want. (Primary care giver respondent 7 in
FGD #201)
When health workers were asked during FGDs about
payments from patients, some stated that this did not
happen, but that patients were told to buy supplies from
drug shops or pharmacies when the facilitys supplies
were finished. However, others did inform us that they
charged patients for services. Volunteers reported that
such charges, and sales of record books and other com-
modities including syringes and gloves on site provided
much needed income. These volunteer workers are
unofficial and unpaid but their presence was ubiquitous at
health facilities in this study, and official health workers
reported they were an important human resource.
Negotiating positions of power in the enactment of
health care
Our analysis suggests that social relationships are at the
heart of the enactment of good quality health care. Re-
strictions can be noted in absolute numbers of resources,
and health worker abilities to provide technically and
interpersonally good quality health care. Beyond these ab-
solute restrictions, our analysis suggests a more dynamic
situation in which managers, health workers and health
seekers make decisions about when to use different
Page 7 of 12
resources and skills, related to their negotiation of posi-
tions of power. This can be exemplified through examples
at health centres and in the wider district.
Negotiating power in health centres
Two major power differentials were recognized by
participants in the health centre arena: between
health workers and patients, and between higher level
cadre health workers and those with lower or no
qualifications.
Health workers described how they exercise their power
to refuse or provide substandard or rude care to certain
patient groups, particularly patients who they considered
not to have any monetary or social capital to offer in
return for services. This was most starkly exemplified by
health workers who undertook spontaneous role-plays to
demonstrate to us the differences between how they
treated patients of different socioeconomic backgrounds,
admitting that a better off client would be warmly
welcomed with a good smile, leaving other activities to
offer services, whereas an untidy-looking, poor client
would likely have to sit and wait, be criticized for atten-
ding in that state, spoken to with scaring words and told
I cant touch you when you are dirty.
Community member narratives included many exam-
ples of this power at play, experiencing that waiting
times, the level of interest expressed by the health
worker for their concerns, and distribution of resources
depended on a care seekers alignment with health
centre culture, identified through their dress, manner,
language and ethnicity.
There are those [health workers] who just look
at you. When you arrive, they just continue
conversing with their friends as though they have
not seen you the patient.
She will just sit there and continue speaking her
English. For you, you will sit there and she will help
her friend whom she knows, who will come from the
other side [end of the queue]. . . . She skips you and
yet the child is breathing so badly and then she will
attend to other person while for you, you are just
there. (Primary care giver, respondent 5 in FGD #209)
Knowing how to present oneself at a health centre was
seen as a great advantage in gaining access to quality ser-
vices. Showing ability to pay for services was one strategy
used, but beyond this, community members described
portraying themselves in a particular way during a visit,
even showing a status of power above the health worker,
as well as making efforts to become familiar with health
workers outside of the health centre.
Chandler et al. Human Resources for Health 2013, 11:13
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For me when I reach [the health centre], I use any
trick until I see that I talk well or speak with him well
. . . there is a way I can come and talk to that person
like someone who knows him. Like knowing his tribe,
something like that. (Male household head,
respondent 1 in FGD #210)
Maybe if he asks me where I come from as they do
now days, I can deceive that I come from Gulu, that
way, or even from the barracks [All laugh]. They will
develop some fear, that maybe this person has come
to spy on us, so let us give him drugs as required.
I have done this before and got better services.
(Male household head, respondent 8 in FGD #208)
In spite of using these strategies to negotiate power and
gain access to care, community members felt that it
should not be necessary to resort to this. They expressed a
desire that health workers provide equitable services rou-
tinely. This was often expressed in terms of wanting health
workers to recognize that they as patients are human, and
this should mean giving help when one is in need.
For me, I was thinking that these health workers are
people, like us. They should see what happens to them,
maybe if a relative is sick or has died. Normally when
you have a patient or lose one, we need encouraging
words. So they were supposed to work with good hearts,
knowing that the government sends these services to
everyone, and pays them [the health workers] (Male
household head, respondent 1 in FGD #206)
Power differentials between health workers of differ-
ent cadres also contributed to how health care was
enacted. For example, seeking informal payments
from patients or work-related opportunities was
attempted by all levels of health worker, but mecha-
nisms for doing so were more straightforward for
those in positions of power, big people, who were
reported to seek opportunities to the disadvantage of
their lower level colleagues through use of their posi-
tions of power.
But basically, sister, you being a person, a volunteer
here and the in-charge or the big person has said
no selling of anything within here and you are
caught, you are a volunteer and you will not be
transferred anywhere else. . . . You have to go and
tell your friend that you go and give five hundred
[to the health worker, he] will just give you
treatment. So being a subject here you have to
abide by the law, or the in-charge, because he is
the one to ask for money [others laugh]!
(Volunteer, respondent 5 in FGD #106)
Page 8 of 12
The power of in-charges to decide who among staff
can receive benefits was also noted by respondents, who
reported biased choices based on favouritism or tribal-
ism, with results of resentment among colleagues.
Like I had told you about workshops, you find that
they select only one person. Like if someone has been
trained on malaria, if there happens to be another
workshop, still they send the same person and yet
there are other people who are equally bright but they
dont know any knowledge about malaria. So because
they know that there is money, they always send that
person to benefit. And actually there is tribalism, like
now, for us who are from very far away, with this
system of decentralization, they consider their home
girls and boys. Then for us who are from very far, you
find that you are left behind all the time. . . . So there
is that tribalism and segregation. (Enrolled nurse in
HC01, interview #20)
The consequences of the observations of power abuses
by senior colleagues led to the need to instigate alterna-
tive survival strategies, especially for those with little or
no salary. This inevitably compromised the quality of
care they provided to patients, who were targeted as
sources of income rather than seen as in need of care.
Volunteers reported that they might charge around 500
shillings (approximately 0.25 USD at the time of the
study) for helping patients (for example those in need of
maternity care or for dressing dirty wounds):
A patient who was having wounds, dirty wounds, so
maybe you ask something from him, or I dont know,
otherwise some also demand some money, for maybe
dressing the wound . . . for the service rendered.
(Volunteer, respondent 4 in FGD #106)
Negotiating power in the district
We observed that the quality with which health care was
enacted was also dependent upon the ways power was ne-
gotiated within districts. Here we describe this in terms of
relationships between district officials and health centre
staff, although we also noted the importance of negotiating
power within households for accessing care, which is
outside of the focus of this analysis.
Power negotiations were evident in the chronic
problems of drug stock outages at the time of the
study, where local political campaigns pointed blame
at health workers for stealing drugs. Health workers
in this study reported feeling powerless in the face of
these critiques - unable to acquire the drugs they needed
through requisitions to the district and reluctant to
suggest that patients purchase drugs from pharmacies for
fear of being reported as selling stolen drugs.
Chandler et al. Human Resources for Health 2013, 11:13
http://www.human-resources-health.com/content/11/1/13
Those politicians just stand there and say, Drugs have
been taken to the health unit and the nurses are
stealing them, which is not true. It may be happening
in certain places but at least they must watch and see.
It is not in every place. (In-charge of a HCII,
respondent 2 in FGD #104)
In most cases you find that the political will is not
working hand in hand with the health workers and
instead they point fingers, they blame and they
dont bother about the welfare of the health
workers. (High cadre health worker, respondent
12 in FGD #103)
Health workers also spoke of having to negotiate
power held by district level health officials in accessing
other resources, including PHC funds for health centres
and salaries for official staff, which respondents had ex-
perienced being withdrawn for political reasons. Health
workers described taking opportunities of supervision
visits from the district to discuss these challenges for
their health centres, but these visits were scarce and
seldom resulted in hoped for results. This reinforced
health workers feelings of a lack of control in contrast
with their district superiors.
Sometimes we dont get feedback from the district or
Ministry of Health. We send reports every month,
they come to supervise us and get problems from
here and take back there but at times, those problems
are not solved. . . . What I can say is that in most
cases, you find that those who come to supervise are
after fault finding, so such people may not be
beneficial to us. (In-charge at HC13, interview #71)
You find you have a problem and you go [to the
district] and explain to the right person, the person is
just swinging as if its not a problem, something small.
Just because for him he gets his salary, [he] will not
mind much. So you will not have any motivation to
work there [at the health centre]. (High cadre health
worker respondent 1 in FGD #103)
Health centre staff were keen to enter into dialogue
with district staff, if a discussion could be two way.
They were especially keen for high level officials to see
what it is like to work and be treated in their health
centres.
We should also have a regular discussion like this one.
We take long without having [such]. In fact it has not
been happening. If higher ranking officers can do
something like that, because we are just down there
crying and they are just there being bosses. They dont
Page 9 of 12
know what is happening. (In-charge of a HCII,
respondent 9 in FGD #104)
In summary, although health workers and community
members shared a similar view on the qualities desired
in health care, the enactment of these qualities depended
upon social relationships, and in particular, the naviga-
tion of power when differentials were steep.
Discussion
Improving access to good health care is considered cen-
tral to achieving health goals [43]. In Uganda, as in many
countries, interventions to improve access to health care
have focused on structural components of health sys-
tems: intermittent investment in facilities, training of
(some) health workers and changes in fees for services.
So far, these interventions have had limited effect on
health in our study area. We found that valued qualities
in health care went beyond absolute resources and skills,
particularly to positive interpersonal interactions, and
that the enactment of these valued qualities was contin-
gent on navigation of power relationships by different
actors including health care seekers, health workers and
district officials. Those in, or able to imitate, a stronger
social position, and who developed effective strategies to
navigate power, were able to fulfil their immediate objec-
tives most effectively. We argue that achieving aspira-
tions for qualities valued in health care will require a
genuine reorientation of focus by health workers and
their managers towards patients, through renewed
respect and support for these providers as professionals.
The qualities valued in health care reported by health
workers and community members in this study, includ-
ing the emphasis on interpersonal qualities, echo the
findings of others in Uganda [16,44,45] and elsewhere in
Africa [46-48]. We particularly noted the significance of
a good welcome to both health care seekers and
workers. In spite of a wealth of evidence that interper-
sonal qualities are important in patient choices of health
care [49], with consequences for uptake of services
[50,51] and health outcomes [52], relatively few pro-
grams in low-resource settings systematically address
these qualities. This may in part reflect the priorities
entrenched in the biomedical model of the centrality of
technologies and technical skills for identifying standard
disease entities as opposed to patient-centered models
which stress the individuality of patients and providers,
necessitating interpersonal qualities for successful health
care [53]. With limited resources, a focus on interpersonal
aspects of care may seem like icing on the cake. It may
also reflect a recognition of the difficulty of changing the
way individuals behave towards each other, understood to
be part of social context, often conceptualized as a factor
that is difficult to change [54]. Our analysis suggests that,
Chandler et al. Human Resources for Health 2013, 11:13
http://www.human-resources-health.com/content/11/1/13
rather than the social world being a contextual factor, or a
factor only affecting interpersonal aspects of care, all qual-
ities valued in health care in this setting are embedded in
social relationships, which shape how these qualities are
enacted. Thus the social world is the medium through
which care is acquired and provided, and also the potential
medium through which to enable aspirations for qualities
to be met.
Implications for programs
We suggest that changing the way that health care is
enacted, to realize the aspirations of both seekers and pro-
viders of health care, will require a reconceptualization of
services and the different actors who bring these to life. In
their comparison of the organizational models of European
and African health care systems, Blaise and Kegels [55]
note a legacy of extreme standardization and rigidity of
hierarchical command and control systems in Africa. They
caution against interventions that reinforce standardization
and external control, and argue instead that instilling
professionalism may promote more flexibility, patient-
focus and responsiveness. Their caution is supported by
evidence that guideline and skills-oriented interventions
have limited effects on quality of care [11,56] and observa-
tions that peers and perceptions of position among a wider
community of practice play a comparatively more import-
ant role in practice [57]. However, it has been argued that
conventional health system development strategies in
Africa continue to undermine local agency and contribute
to the disempowerment of health workers, managers and
policy-makers at all levels, who feel unable to effect
changes that may improve the quality and impact of ser-
vices [58]. The professionalization of health workers, par-
ticularly of mid-level cadres, whose jobs, resources and
reputations are subject to those in higher positions of
power, could lead to a greater confidence, self-esteem and
value [58]. It is likely that such attempts will be most suc-
cessful if basic monetary needs of health workers are met
first [59]. In turn, better motivated health workers may
have more inclination to deliver better care to patients [7].
Facilitating such shifts in conceptualizations of health
workers, and in turn of patients, will be challenging. The
mode of service expected and promoted by health pro-
grams is situated within powerful discourses emanating
from the fields of development and of biomedicine.
Possibilities for change on the local level may therefore
be limited, although not impossible, especially for de-
centralized systems. Communities of practice, in which
those engaging frequently with each other shape norms
and expectations, may be loci for such change [60], as
has been observed in malaria case management in
Ghana [61]. Annemarie Mol suggests that a medium for
making improvements in health care is through sharing
stories and airing mistakes and uncertainties, in an
Page 10 of 12
environment where individuals are not on the defensive,
noting that currently there is often no room for doubt,
self-criticism, or difficult questions. However, improvement
begins with the recognition that something needs to be im-
proved. [19]. Furthermore, she observes that, rather than a
matter of merely sharing private experiences, telling stories
is a form of public coordination. It is part of how we govern
ourselves and each other. (ibid.). Such story-telling could
be incorporated into approaches that have shown some
success in improving patient-centeredness through building
self-awareness by facilitated reflection and meditation in
Africa [62] and elsewhere [63].
Building on the findings of the research presented in
this paper, we have designed an intervention based on
the qualities for health care aspired to by participants.
This consists of a series of workshops and self-
observation activities to stimulate patient-centered ser-
vices alongside training and tools for the management of
supplies and funds at health centres and training and
supervision in malaria case management including new
rapid diagnostic tests. The intervention also provides
malaria-related supplies to the health sub-district level,
to be requisitioned from health centres through a spe-
cific process. This will be evaluated through a cluster
randomized trial accompanied by a comprehensive
process, context and impact evaluation (clinicaltrials.gov
NCT01024426).
Limitations
A total of 182 health workers and community mem-
bers participated, and we are unable to represent the
breadth and depth of each of their views here. How-
ever, in this article we aimed to present a more
nuanced analysis of the way health care is enacted in
this district of Uganda. Our interpretation draws on
our understanding of participants words and mea-
nings in the context of our theoretical orientation,
outlined above. We suggest that our approach of
working closely as a team throughout data collection
and analysis and challenging our own thinking and
assumptions throughout strengthened the validity of
our interpretation. The generalizability of the findings
may be limited in the specifics but we believe that by
drawing on our empirical data together with insights
from other authors, the concepts may be transferable
to different settings.
Conclusions
In spite of decades of reforms and interventions to
improve health through access to quality health services,
these goals remain unmet in eastern Uganda. In contrast
to the focus of programs on absolute resources and skills,
health-care seekers and providers in this study had unified
aspirations for qualities of health care as a compound of
Chandler et al. Human Resources for Health 2013, 11:13
http://www.human-resources-health.com/content/11/1/13
technical, interpersonal and resource factors. However,
the enactment of these valued qualities was undermined
by the daily struggles of health care seekers and providers
to meet their individual needs, necessitating the navigation
of strong power relationships within health facilities and
the district at large. Those in the weakest position to navi-
gate power had the poorest ability to enact the qualities
they aspired to in health care, whether as providers or
seekers of care. We argue that achieving aspirations for
qualities valued in health care will require a genuine
reorientation of focus by health workers and their
managers towards patients, through a renewed respect
and support for these providers as professionals.
Abbreviations
FGD: Focus group discussion; HC: Health centre; IQR: Interquartile range;
PHC: Primary health care.
Competing interests
The authors declare that they have no competing interests with respect to
the research, authorship, and/or publication of this article.
Authors contributions
CIRC and SGS conceived and designed the study. JK, LT, CN and MK
undertook data collection and analysis with CIRC. All authors contributed to
the interpretation of the data; CIRC drafted the paper and all authors
undertook critical revisions of the manuscript and read and approved the
final manuscript.
Authors information
CIRC, PhD, is a lecturer in social science in the department of Global Health
and Development at the London School of Hygiene & Tropical Medicine,
London, United Kingdom.
JK, BA, is a social scientist at the Infectious Diseases Research Collaboration,
Makerere University College of Health Sciences, Kampala, Uganda.
LT, BUP, is a social scientist at the Infectious Diseases Research Collaboration,
Makerere University, Kampala, Uganda.
CN, BCP, is a social scientist at the Infectious Diseases Research Collaboration,
Makerere University College of Health Sciences, Kampala, Uganda.
MK, BSWSA, is a social scientist at the Infectious Diseases Research Collaboration,
Makerere University College of Health Sciences, Kampala, Uganda.
DD, MSc, is a research fellow in the Department of Clinical Research at the
School of Hygiene & Tropical Medicine, London, United Kingdom.
SGS, MD, PhD, is a clinical senior lecturer in the Department of Clinical
Research at the London School of Hygiene & Tropical Medicine, London,
United Kingdom.
Acknowledgements
We thank the participants who shared their experiences with us. We thank
Loy Sentumbwe and Grace Nyabwolo, who were important members of the
social science team, and Nicholas Wendo for his help with translations. We
thank Joaniter Nankabirwa for her guidance in the study coordination and
Catherine Maiteki-Sebuguzi and Florence Nankya for their support in these
research activities. We thank the District Health Officer of Tororo District, Dr.
David Okumu, for supporting our research. We thank Joanna Reynolds for
giving useful feedback on the draft article. The authors disclose receipt of
the following financial support for the research, authorship, and publication
of this article: The study was funded by the ACT Consortium through a grant
to the London School of Hygiene & Tropical Medicine from the Bill &
Melinda Gates Foundation.
Author details
1
Department of Global Health & Development, London School of Hygiene &
Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK. 2Infectious
Diseases Research Collaboration, Mulago Hospital Complex, Kampala, PO Box
7475, Uganda. 3Department of Clinical Research, London School of Hygiene
& Tropical Medicine, Keppel St, London, WCIE 7HT, UK.
Page 11 of 12
Received: 16 January 2013 Accepted: 28 February 2013
Published: 22 March 2013
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doi:10.1186/1478-4491-11-13
Cite this article as: Chandler et al.: Aspirations for quality health care in
Uganda: How do we get there?. Human Resources for Health 2013 11:13.